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COUNSELING INFORMATION FORMS:

In preparation for counseling, we ask that you fill out the following forms. Please be aware that there are no wrong or right answers to the following questions. Your honest answers will help us to know and serve you better. Simply click on form you'd like to fill out and it will expand.

problem checklist FORM:

PROBLEM CHECK LIST

* Indicates required field

Name *

First

Last

Please mark 1-3 on all that apply (1=Mild, 2=Moderate, 3=Severe).

Abuse at present (sexual, physical, verbal) *

Anger *

Anorexia *

Anxiety *

Apathy *

Bitterness *

Bulimia *

Children *

Communication *

Conflict (Fights) *

Deception *

Decision making *

Depression *

Drastic changes in life circumstances/lifestyle *

Drunkenness *

Drugs *

Envy or jealousy *

Fear *

Finances *

Gambling *

Gluttony *

Guilt *

Grief *

Health *

Homosexuality *

Infidelity *

In-laws *

Loneliness *

Memory *

Mental Confusion *

Moodiness *

Overwhelmed *

Perfectionism *

Poor Concentration *

Pornogrophy *

Procrastination *

Rebellion *

Same sex attraction *

Self-injury *

Sex (lust, impotence...) *

Sleep *

Other *

Submit

pre-counseling questions form:

PRE-COUNSELING QUESTIONS

* Indicates required field

Name *

First

Last

Please take some time to think through what has been happening in your life that brings you to counseling. This section will help us get to know your current situation better, in order to match you with a counselor and/or provide the best help. Use the following questions as a guide to journal about what is going on in your life and heart.

1. What has brought you here? Describe the main problem in your life as you see it. (Include when it began and any other very significant events or information.) *

2. What have you done to try and resolve the problem on your own? *

3. Why are you now wanting to seek help? *

4. What types of thoughts come to your mind in your current situation when you feel disappointed, discouraged, angry, and/or fearful about the situation? *

5. What are you hoping we can do for you? *

6. Is there any other information you think we should know? *

Submit

Information and agreement form:

Please read the form below and then sign this form acknowledging that you have read and agree to our counseling procedures at DBCC.

informed consent form:

Please read the form below and then sign this form acknowledging that you understand the nature and conditions of counseling at DBCC.

Deposit

COUNSELING INFORMATION FORMS:

PERSONAL & FAMILY INFORMATION

HEALTH INFORMATION

BACKGROUND INFORMATION

Other and Later Life:

SPIRITUAL LIFE INFORMATION:

PROBLEM CHECK LIST

PRE-COUNSELING QUESTIONS